WATCHOUT Learning from others’ accidents
Captain Paul Drouin, FNI, Editor of The Nautical Institute’s Mariners’ Alerting and Reporting Scheme (MARS), discusses how we can learn from other people’s accidents and incidents at sea to make the marine environment safer for us all
Accidents will always happen, of course. Some people have used this kernel of truth to question the usefulness of accident reports and the purported goal of these reports: learning from the mistakes of others. They suggest that these reports often just point the finger to a guilty party and make the mariner look stupid, incompetent or both. However, this line of reasoning is out of phase with modern ideas, such as continuous improvement. Naturally, the best accident reports do not mention names of individuals involved in the casualty. Instead, they strive to shine a light on the underlying conditions that allowed the accident to happen.
The report on the Herald of Free Enterprise capsizing in 1987 was groundbreaking, in that it was one of the first to follow the chain of underlying conditions and causal factors all the way to the top company management. Indeed, as modern investigation techniques have since shown, unsafe conditions and unsafe acts onboard vessels often have an intimate and direct link to the management of those vessels. The report has been credited as the catalyst and inspiration for the International Safety Management (ISM) Code that has, over the past 20 years, been an important contributor to the maritime industry in conceptualising a framework for safety and a safety culture.
People are hard-wired to learn from their own mistakes. If you put your hand on a hot stove top, you will probably not do it again! So, what if you tell someone who has never experienced such a mishap, ‘Be careful, that stovetop is very hot and can burn you’? They will listen, analyse and probably think it true and good. Yet their appreciation for the hotness of the stove top – for the searing burn – will not be first-hand and, as such, will not be anchored in their brain quite so profoundly as for the person who actually experienced the event. This is the paradigm that must be overcome.
THE MORE KNOWLEDGE MARINERS HAVE OF OTHER ACCIDENTS, NOT JUST THEIR OWN, THE BETTER AND MORE HONED THEIR RISK APPRECIATION WILL BECOME
One of the tools that can help change how this work is done is the development of company- and ship-specific procedures. Procedures are a distillation of best practices that themselves are often honed from past operations that have gone well, but also from those that have not gone well. There is obvious benefit to documenting and adhering to best practice. This was one of the underlying lessons of the Herald of Free Enterprise disaster and the resulting ISM Code.
So, the more knowledge mariners have of other accidents, not just their own, the better and more honed their risk appreciation will become. This, in turn, should also lead to a more complete buyin for procedural integrity and accident reporting. In short, a safer ship and safer crew. Today, accident reports can be easily gleaned from the Internet as many countries publish their reports on the web.
Several can be found under the umbrella of the Marine Accident Investigator’s International Forum online: https://maiif. org/links/members-investigation-reports. P&I Clubs also publish loss control bulletins and lessons learned that can easily be accessed online. Then, of course, you can read MARS reports in The Nautical Institute’s own Seaways magazine, or on the free online database, which are themselves edited versions of published reports and members’ contributions.
If you find our accident reports useful, check out The Nautical Institute’s Maritime Accident Reporting Scheme (MARS). A fully searchable database of incident reports and lessons, updated every month. Seen a problem yourself? Email the editor at Mariners’ Alerting and Reporting Scheme email@example.com and help others learn from your experience. All reports are confidential – we will never identify you or your ship.